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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME. 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � i T ` D 7 U� Page I-- of _ 2— Facility Address: City: Inspection Date: L) l 1 FA #: PR #: Program Element: V o� a � Pz Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z1320 gallons in tanks and containers over 55 gallons. / Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: D5 1.7 D 725- (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: Total Capacity: % d 0 D i� gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) Eh -Containers (282 1) #of Containers: 'y TA#: D (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: A S 4 R4 Lr e / Total Capacity: //0 gallons Install Date: (per tank or cumulative for containers by product type) EBZTank(2820) Cltainers (2821)#of Containers: , TA 7� 7% <)gallons 3 (>250 gallons) ��55 gallons and 0 gallons) 1/ a -j 11Product Type: Total Capacity: Install Date: (per tank or cumulative fo ontainers by p uct type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: f TA#: B j a2 p7"o2 0 4 (>250 gallons) (>55 gallons and QSO gallons) _ Product Type: �� Total Capacity: �,� gallons � Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and <250 gallons) 5 Product Type: �,ti� � �.tit,F. � C __ Total Capacity: L Cl; gallons (per tank or cumulative for containers by product type) Install Date: ' `"- Total Capacity this Page:r� gallons Total Capacity for Site: gallons Comments: B l( EHD Inspector: Reviewed Date; By Initial:_) j ' ' Entered By Initial: q0 EHD 28-01 01/16/08